Winner
Leicester City TotalCare COPD Service
Summary of work
The Leicester City TotalCare service is an innovative scheme that has utilised a real-time communication system (telehealth) to support patient well-being and health improvements in patients with COPD. This is the first demonstration in the UK of integrating health coaching, telehealth and respiratory nurse expertise to deliver a single model of care with the patient experience at the centre.
The vision for this service was to shift the balance and focus from a model that responded to illness to one which promotes health and well-being. The service has been recognised for its important role in reducing health inequalities, reducing demand on acute services and enhancing the patient experience.
Outcomes were significant improvements attributable to the collaborative approach in delivering a new model of care:
- 164 avoided emergency COPD admissions (against target of 70) for the period December 2012 to November 2013, equating to QIPP savings of approximately £363,000
- Patient improvements in self-management, education and confidence
- An enhanced primary and community services care pathway delivery, supporting the ‘self-care’ model to patients
- Successful collaboration between CCG, LPT and third parties in providing primary and community based COPD care management
- Improved clinician and patient awareness of COPD management.
Judges’ comments
This entry contains all the elements that will shape the future management of chronic conditions; technology, collaboration and innovative processes. It reshaped the care pathway and reduced hospitalisations. It is scalable, transferable and will be a model for other commissioners. The NHS needs the benefits this entry provides.
